103911016-10-7-2019-04-CC-NLOI-BGQNVG-20191007104755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 103911016
Report Date: 10/07/2019
Date Signed: 10/07/2019 10:48:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GOMEZ, MA DEL FAMILY CHILD CARE		FACILITY NUMBER:	103911016
ADMINISTRATOR:	GOMEZ, MA DEL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 289-3865
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	14	CENSUS: 0	DATE:	10/07/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ma del Carmen Gomez		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Norma Lomeli met with Applicant, Ma del Carmen Gomez for a pre-licensing/change of location with a capacity increase inspection. Present at time of inspection, was licensee and Licensee's Assistant, Azucena Martinez. Applicant and two minor children reside in the home. Verified licensee, licensee’s assistant’s CPR and First Aid are current. Applicant completed it through Pediatric Plus with certified EMSA stickers and expires on 3/30/2021. Applicant's Assistant completed it through American Red Cross and expires on 4/3/2021. Background clearances are discussed and LIS 531 is signed indicating that the adults currently living in the home and/or providing care and supervision to children have a criminal record clearance. Fire clearance was granted on September 19, 2019. Facility was inspected inside and outside as shown on the facility sketch and the following items were discussed: Fire clearance was received on September 26, 2019. Fire alarm is located in the living room on the wall. This is a two story, three bedrooms and two baths home and upstairs area will be off-limits to the day-care children. There is a door gate at the bottom of the stairs making upstairs area inaccessible. There are two bedrooms downstairs that are made inaccessible by the use of a plastic door knob cover. Care and supervision will be provided in the living room, kitchen, down stairs bathroom and applicant states that converted garage into living space that has heating and ventilation will(Continued on LIC809-C):

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma Lomeli	TELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, MA DEL FAMILY CHILD CARE	FACILITY NUMBER: 103911016
	VISIT DATE: 10/07/2019

NARRATIVE

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There is a fireplace in the living room that applicant states it will not be used during day-care hours.
LPA observed children size furniture, safe toys and books for the children. There is a diaper changing table. Children will nap in the living room on mats. Infants will nap in the living room inside a play yard. Applicant understands she is to supervise children at all times.
Facility has 3A40BC fire extinguisher, smoke alarm, carbon monoxide alarm and first aid kit in place.
Preventative Health and Safety class was completed on September 17, 2016.
Knives and medications are stored inside a top kitchen cabinet inaccessible to the day care children.
Advised applicant fire drills are to be conducted once every 6 months and must be documented with date and time. A fire drill log was provided as an example.
Applicant is advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
There are no bodies of water in the home or premises.
There is a 35-gallon fish tank with a tight fitted cover that is kept in the living room. Applicant is advised it is her responsibility to ensure the safety of children in care at all times from the pets.
Applicant states there are no weapons, firearms, ammunition or poisons in the home or premises.
Applicant is reminded that any advertising (of day-care) such as business cards, flyers/posters, and/or signs must include facility number as per Title 22 Regulation "Advertisements and License Number" 102359 (a).
Applicant states the home is smoke-free.
Applicant states she will be transporting day care children. Applicant understands that she must have proper restraints and/or car seats for all the children under her care when transporting children.
Fenced backyard has a cemented area for the children to play. LPA observed Little Tikes Sand Table and a picnic bench, Step 2 playhouse with slide, child size furniture, safe toys and books for the children. There is a small gazebo for shade.
SB 792 immunizations verified and on file.

(Continued on LIC809-C):

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma Lomeli	TELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2019

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, MA DEL FAMILY CHILD CARE	FACILITY NUMBER: 103911016
	VISIT DATE: 10/07/2019

NARRATIVE

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Applicant complete the Mandated Reporter Training on January 10, 2018.
LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given to applicant.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Required postings, forms packet, which included Parent Notification Requirement and LIC9224 were provided and discussed in detail. Applicant is advised that she may access CCLD website at www.ccld.ca.gov for additional forms and licensing updates. She is also reminded that it is her responsibility to read the regulations periodically. Applicant states she will operate her day care Monday through Saturday from 5:00 AM to 10:00 PM and as arranged. No overnight care will be provided.

Licensure as a Large Family Day Care Home capacity of 14 children ages under 18 years will be recommended effective October 8, 2019.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma Lomeli	TELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2019

LIC809 (FAS) - (06/04)

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